Detailed Information

NPI Number 1760710172 has the “Individual” type of ownership and has been
registered to the following primary business legal name (which is a provider name or healthcare organization name) — HARRIET JEAN MATTLIN NP.
Records indicate that the provider gender is “Female”.
The enumeration date of this NPI Number is 11/23/2009.
NPI Numer information was last updated at 03/25/2014.

The provider is physically located (Business Practice Location) at:

525 MADRONA AVE
PORT ORFORD
, OR
97465-9552
US

The provider can be reached at his practice location using the following numbers:

Phone 541-332-3861Fax 541-332-0250

The provider's official mailing address is:

94220 4TH ST
GOLD BEACH
, OR
97444-7756
US

The contact numbers associated with the mailing address are:

Phone 541-247-3181Fax 541-247-3122

The authorized official registered with the “1760710172” NPI Number
is .

The authorized official title (position) is .

You can reach the authorized official at the following phone number .

Scope of Practice

The following information about the specialty of the provider is available:

#

Taxonomy Code

Taxonomy

License Number

License Number State

1

363L00000X

Nurse Practitioner

15398

CA

2

363LF0000X

Family

15398

CA

3

363LF0000X

Family

201400210NP-PP

OR

4

363L00000X

Nurse Practitioner

201400209RN

OR

Legacy Identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

A sole proprietor is the sole (the only) owner of a business that is not incorporated; that unincorporated business is a sole proprietorship.

In a sole proprietorship, the sole proprietor owns all of the assets of the business and is solely liable for all of the debts of the business.

There is no difference between a sole proprietorship and a sole proprietor; they are legally a single entity: an individual.

In terms of NPI assignment, a sole proprietor is an Entity type 1 (Individual) and is eligible for only one NPI (the sole proprietorship business is not eligible for its own NPI).

As an individual, a sole proprietorship cannot be a subpart and cannot have subparts. (See NPI Final Rule for information about subparts.)

A sole proprietorship may or may not have employees.

Often, the IRS assigns an EIN to a sole proprietorship in order to protect the sole proprietor's SSN from disclosure in claims or on W-2s. NPPES does not capture a sole proprietorship's EIN.

Many types of health care providers could be sole proprietorships (for example, group practices, pharmacies, home health agencies).

4

Provider Last Name (Legal Name)

MATTLIN

The last name of the provider (if an individual). If the provider is an individual, this is the legal name. This name must match the name on file with the Social Security Administration (SSA). In addition, the date of birth must match that on file with SSA. (First and last names are required for initial applications.) The First, Middle, Last and Credential(s) fields allow the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters.

5

Provider First Name

HARRIET

The first name of the provider, if the provider is an individual.

6

Provider Middle Name

JEAN

The middle name of the provider, if the provider is an individual.

7

Provider Credential Text

NP

The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.

8

Provider First Line Business Mailing Address

94220 4TH ST

The first line mailing address of the provider being identified. This data element may contain the same information as ''Provider first line location address''.

9

Provider Business Mailing Address City Name

GOLD BEACH

The City name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address City name''.

10

Provider Business Mailing Address State Name

OR

The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address State name''.

11

Provider Business Mailing Address Postal Code

97444-7756

The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ''Provider location address postal code''.

12

Provider Business Mailing Address Country Code

US

The country code in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address country code''.

13

Provider Business Mailing Address Telephone Number

541-247-3181

The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ''Provider location address telephone number''.

14

Provider Business Mailing Address Fax Number

541-247-3122

The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address fax number''.

15

Provider First Line Business Practice Location Address

525 MADRONA AVE

The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.

16

Provider Business Practice Location Address City Name

PORT ORFORD

The city name in the location address of the provider being identified.

17

Provider Business Practice Location Address State Name

OR

The State or Province name in the location address of the provider being identified.

18

Provider Business Practice Location Address Postal Code

97465-9552

The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.

19

Provider Business Practice Location Address Country Code

US

The country code in the location address of the provider being identified.

20

Provider Business Practice Location Address Telephone Number

541-332-3861

The telephone number associated with the location address of the provider being identified.

21

Provider Business Practice Location Address Fax Number

541-332-0250

The fax number associated with the location address of the provider being identified.

22

Provider Enumeration Date

11/23/2009

The date the provider was assigned a unique identifier (assigned an NPI).

23

Last Update Date

03/25/2014

The date that a record was last updated or changed.

24

Provider Gender Code

F

The code designating the provider's gender if the provider is a person.

25

Provider Gender

Female

The provider's gender if the provider is a person.

26

Healthcare Provider Taxonomy Code #1

363L00000X

The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization.

27

Healthcare Provider Taxonomy 1

Nurse Practitioner

Healthcare Provider Taxonomy #1

28

Provider License Number 1

15398

Certain taxonomy selections will require you to enter your license number and the state where the license was issued. Select Foreign Country in the state drop down box if the license was issued outside of United States. The License Number field allows the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. DO NOT report the Social Security Number (SSN), IRS Individual Taxpayer Identification Number (ITIN) in this section.

29

Provider License Number State Code 1

CA

Provider License Number State Code #1

30

Healthcare Provider Primary Taxonomy Switch 1

N

Primary Taxonomy:

X - The primary taxonomy switch is Not Answered;

Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);

N - The taxonomy is not the primary taxonomy.

31

Healthcare Provider Taxonomy Code 2

363LF0000X

Healthcare Provider Taxonomy Code #2

32

Healthcare Provider Taxonomy 2

Family

Healthcare Provider Taxonomy #2

33

Provider License Number 2

15398

Provider License Number #2

34

Provider License Number State Code 2

CA

Provider License Number State Code #2

35

Healthcare Provider Primary Taxonomy Switch 2

N

Primary Taxonomy:

X - The primary taxonomy switch is Not Answered;

Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);

N - The taxonomy is not the primary taxonomy.

36

Healthcare Provider Taxonomy Code 3

363LF0000X

Healthcare Provider Taxonomy Code #3

37

Healthcare Provider Taxonomy 3

Family

Healthcare Provider Taxonomy #3

38

Provider License Number 3

201400210NP-PP

Provider License Number #3

39

Provider License Number State Code 3

OR

Provider License Number State Code #3

40

Healthcare Provider Primary Taxonomy Switch 3

N

Primary Taxonomy:

X - The primary taxonomy switch is Not Answered;

Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);

N - The taxonomy is not the primary taxonomy.

41

Healthcare Provider Taxonomy Code 4

363L00000X

Healthcare Provider Taxonomy Code #4

42

Healthcare Provider Taxonomy 4

Nurse Practitioner

Healthcare Provider Taxonomy #4

43

Provider License Number 4

201400209RN

Provider License Number #4

44

Provider License Number State Code 4

OR

Provider License Number State Code #4

45

Healthcare Provider Primary Taxonomy Switch 4

Y

Primary Taxonomy:

X - The primary taxonomy switch is Not Answered;

Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);